A 2018 study in The Lancet showed that 5 million people in low- to middle-income countries died in 2016 from poor quality healthcare, and an additional 1.5 million people from not having access to care itself.
Indeed, to save lives and achieve health for all, we need to improve access to health services and the quality of those services themselves. This is especially urgent for the 370 million Indigenous peoples living in more than 70 countries worldwide, who experience even more profound health challenges compared to the overall population. Data from 16 low- and middle-income countries show that Indigenous women and adolescent girls are significantly less likely to benefit from health services and experience significantly worse maternal health outcomes than majority populations. In both high- and low-to-middle-income countries, Indigenous populations generally have a lower life expectancy than non-indigenous populations, and a higher incidence of non-communicable diseases, like diabetes or mental health disorders, and infectious diseases, such as tuberculosis.
For us at the Johnson & Johnson Center for Health Worker Innovation, improving access to care and ensuring quality care means investing in the people on the front lines who can deliver quality care worldwide. Indigenous midwives, in particular, are a crucial part of the global health workforce and play an irreplaceable role in providing culturally appropriate care to women and families of the Indigenous peoples.
The Center aims to raise the bar for midwifery education through interventions at three points in the midwifery education pathway: pre-service education, preceptorship, and licensing. From the Americas to the Asia-Pacific region, read on for three examples of how we are supporting Indigenous midwifery education.
Canada: Innovate to bring midwifery education back to Indigenous communities
The challenges facing Canadian Indigenous midwifery education and training are three-fold: 1) their lack of recognition as safe, clinically excellent practitioners; 2) geographic barriers to mainstream midwifery education programs due to their location in larger urban centers, as opposed to being community-based; and 3) a lack of Indigenous-led curricula for Indigenous midwifery students within mainstream programs.
In 2018, Indigenous midwives across Canada gathered to address the first challenge: defining themselves as safe, competent practitioners who also bring critical cultural practices to Indigenous families in the childbearing year and beyond. During a two-day working session convened by the National Aboriginal Council of Midwives (NACM), the midwives outlined the beginning of a ground-breaking document publicly launched in 2019: Indigenous Midwifery Knowledge & Skills: A Framework of Competencies. The competencies outline the clinical and cultural skills that make up an Indigenous midwife’s sacred medicine bundle that she carries throughout her professional life. The Competency Framework is a foundational component of a broader federally supported and NACM-led initiative to improve access to midwifery services in First Nation and Inuit communities.
To increase the number of competent Indigenous midwives, so that Indigenous women are not forced to give birth alone in a health facility far from their community, NACM has envisioned an innovation in Indigenous Midwifery Education that returns to the original way of teaching and training, rematriating midwifery in order to bring birth as close to home as possible. The new education program will offer competency-based apprenticeship for aspiring Indigenous midwives within their communities. They will begin with two of the most promising educational pathways identified: 1) a laddered apprenticeship program that is located entirely within communities; and 2) a hybrid apprenticeship with linkages to mainstream midwifery education programs. The objective is to grow and sustain the profession of Indigenous Midwifery by diversifying pathways to midwifery education.
In Canada, Indigenous Midwifery is not just about safe and respectable maternity care. It is about truth and reconciliation, healing and protecting the sacred start of a new family. NACM has already seen a positive response to the Competency Framework from Indigenous communities, midwifery educators, government agencies, and other medical professionals. These partners and supporters are critical to instituting community-driven midwifery education, increasing the Indigenous Midwifery Workforce and ultimately bringing clinically and culturally safe birth back to Indigenous families and communities.
Mexico: Raise midwifery pre-service education to global midwifery competency standard
Mexico faces challenges in maternal and newborn health: The lack of full midwifery services is compounded by rising Cesarean-section rates across the country. To reduce unnecessary C-section procedures and meet currently unmet needs in maternal newborn health services, The Center has partnered with UNFPA Mexico to strengthen the country’s midwifery workforce, starting with pre-service education.
Working closely with midwifery schools and universities seeking to open midwifery schools, UNFPA conducted a quality assessment and identified several key gaps in existing midwifery education programs, including but not limited to: (1) lack of up-to-date curricula that meet the global midwifery competency framework; (2) limited time allocated to hands-on practice due to lack of teaching equipment such as anatomical models; (3) and lack of clinical sites where students can apply evidence-based practice. Since 2017, we have worked with UNFPA to address these gaps, and now 13 midwifery schools offer newly revised midwifery higher education programs that address the gaps identified through the quality assessment and incorporate improved capacity building of teachers and clinical practices.
With our partner Nueve Lunas, we have also worked to incorporate the ancestral knowledge of traditional and Indigenous midwives into formal training modules. The manual, Hands of a Midwife, was also edited to include guidelines that support clinical care in rural communities and complement training on emergencies and complications during pregnancy. Our work does not end in clinics and training programs—we have also supported our partners in creating radio clips, videos and other materials to raise awareness about healthy pregnancies among healthcare providers and disseminate these materials through Indigenous communities. Comunidad de Partería is one of the most recent and updated web portals for learning and connection for midwives and other healthcare workers to improve Mexico's maternal health.
Research by the National Institute of Public Health shows that deliveries by midwives in Mexico cost almost half what they cost when done by doctors. And midwives educated to the global standard can provide 87% of all maternal newborn health services. Through our partnership with UNFPA Mexico and other key national stakeholders, we hope to elevate the profile of professional midwives, and raise the education standard and quality for the midwifery workforce in Mexico.
Vietnam: Professionalize Indigenous midwives through facility-based preceptorship
Vietnam has made remarkable progress in reducing maternal mortality and under 5-year-old child mortality. However, progress among ethnic groups in remote, mountainous areas is significantly behind: The under-5 mortality rate among ethnic minorities is 3.5 times higher than that of the rate of Kinh majority people, and the maternal mortality rate is 3 times higher than the rate in urban areas.
Provinces in remote mountainous areas have several different ethnic minorities, each of which has their own culture and traditions. For expectant mothers from these communities, geographical or social barriers can make it difficult for them to deliver their babies within the formal healthcare system. As a result, only a small percentage of ethnic minority pregnant women have access to formal healthcare facilities to give birth and the majority deliver their babies at home, often without the help of a trained or skilled birth attendant.
To meet the needs of Indigenous women and bring quality maternal, neonatal and child health services to Indigenous communities, Johnson & Johnson in partnership with UNICEF and the Ministry of Health of Vietnam launched a project to improve maternal and newborn health in 2016.
This program’s core competencies include the capacity building of Indigenous midwives, who reside in the communities they serve, speak the local language, and understand local socio-cultural norms. These midwives are selected and placed in either a 6-month intensive midwifery training or a 5-day refresh training program at provincial medical schools and provincial hospitals for preceptorship. They are trained on essential practices for maternal and early newborn care, providing health education and conducting referrals in case of complications.
Through hands-on experience that includes role-playing and practice at health facilities to support new mothers, they gain the tools and training they need to provide birth assistance for women in their villages. After completing the training program, ethnic minority village midwives are deployed and bring quality health services back to their villages. Since the launch of our partnership, more than 600 ethnic minority midwives and 1,500 health staff have completed these training and are now equipped to bridge health gaps and strengthen Vietnam’s overall health system.
“In villages with midwives in operation, the maternal and newborn mortality rates significantly decreased, even down to 0 in some areas. Most midwives expressed strong passion for their work, as well as willingness to overcome challenges to carry out their tasks and support the communities.” - Health staff in Dien Bien, a target province of the program
Alisha Nicole Apale from National Aboriginal Council of Midwives also contributed to this article.